Understanding Dental Insurance Appeal Laws

Dental insurance is a form of health insurance that pays for any work associated with maintaining or restoring the natural function of teeth. This includes routine dental examinations, root canals, periodontics and any prosthetics or oral surgery that may be needed. In many cases, dental procedures that go beyond a simple cleaning and exam must be approved in advance by the insurance company. If an insured feels that their request for approval was denied unfairly, they have an opportunity under state law and the federal ERISA laws, which govern group benefit plans. The process for appeal requires some time in order for a cooling off to take place and possible mediation or resolution before it arises to the level of a civil action. The process for appealing dental insurance denials is the same as it is for other types of health insurance policies.

Following the Insurer’s Predetermination Process

Dental insurance requires that some preauthorization or predetermination take place prior to the commencement of a procedure, such as a root canal. The process for predetermination is usually followed by the dentist to ensure that they will be paid for the work performed in behalf of the patient. Predeterminations done by an insurance company is not a process that is required under state law.

An insurance company that denies providing benefits for a required procedure must communicate in writing to the insured about their decision. This required communication varies by state. The written correspondence is typically required in as little as 30 to 45 days. Before a claimant or insured can institute any type of process against the insurer, including an appeal, they must receive the communication concerning the denial.

Requesting an Appeal of the Decision

Once the insured receives the communication from the insurer regarding the proposed procedure, the insured may request an appeal to that decision. This appeal request must go through the insurance company as the first point of contact. Once the appeal is received by the insurer, they have a prescribed period of time in which to respond. In some states if the insurer fails to act within the appeal review process time frame, the claim must be paid.

During the appeal process, which takes up to the time allowed under state law, the insurance company will review all communications and other documents related to the denial of benefits. The insurer may request information from the underwriter or analyst making the decision, the dentist and any other person with information concerning this case. If the insurer still determines that their decision was correct and the claim is denied, a notification of their final decision will be sent. This notification should also contain information in more detail as to what the basis of the insurer’s decision and your right under ERISA and state law to pursue further legal action.

Pursuing an Additional Appeal

You may pursue under law a civil case against the insurer to compel them to honor the claim and pay benefits to you. In this case, a 60-day waiting period must be observed (in most states) which is known as the cooling-off period. After the 60-day per has elapsed, you are given a period of up to 3 to 5 years in which to pursue a claim, depending on the state.

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